employee group term life certificate of insurance · employee group term life certificate of...

MHC-96-13181.24 Rev 3-2009 Minnesota Life 1 EdF77744 9-2012

Employee Group Term Life Certificate of Insurance Minnesota Life Insurance Company - A Securian Company 400 Robert Street North • St. Paul, Minnesota 55101-2098 • 1-866-293-6047 POLICYHOLDER: Missouri Department of Transportation and Missouri State Highway Patrol

POLICY NUMBER: 34125

Read Your Certificate Carefully You are insured under the group policy shown on the specifications page attached to this certificate. This certificate summarizes the principal provisions of the group policy that affect you. The provisions summarized in this certificate are subject in every respect to the group policy. You may examine the group policy at the principal office of the policyholder during regular working hours.

Right to Cancel It is important to us that you are satisfied with this certificate after it is issued. If you are not satisfied with this certificate, you may cancel it by delivering or mailing a

written notice or sending a telegram to Minnesota Life Insurance Company (Minnesota Life), 400 Robert Street North, St. Paul, Minnesota 55101-2098 and returning the certificate before midnight of the 30th day after you received this certificate. Notice given by mail and return of the certificate by mail are effective on being postmarked, properly addressed, and postage prepaid. If you return this certificate, you will receive, within 10 days of the date we receive a notice of cancellation, a full refund of any premiums you have paid. Upon cancellation of this certificate, it will be void as if it had never been issued.

Secretary President TABLE OF CONTENTS Definitions .......................................................................... 2 General Information .......................................................... 2 Premiums .......................................................................... 3 Death Benefit..................................................................... 4

Termination ........................................................................ 5 Conversion Right ............................................................... 5 Additional Information ........................................................ 6

GROUP TERM LIFE CERTIFICATE OF INSURANCE

F. MHC-50393.24 Rev 3-2009 A

CERTIFICATE SPECIFICATIONS PAGE

GENERAL INFORMATION POLICYHOLDER:

Missouri Department of Transportation and Missouri State Highway Patrol

POLICY NO.: 34125-G

ASSOCIATED COMPANIES:

All subsidiaries and affiliates reported to Minnesota Life by the policyholder for inclusion in the policy.

POLICY EFFECTIVE DATE:

January 1, 2013

This certificate and/or certificate specifications page replaces any and all certificates and/or certificate specifications pages previously issued to you under the group policy. Please replace any certificate and/or certificate specifications page previously issued to you with this new certificate and/or specifications page. GROUP:

The group is composed of all active full-time, permanent part-time, retirees and disabled employees or seasonal employees of the Missouri Highway and Transportation Commission, Missouri Department of Transportation, Missouri State Highway Patrol, or MoDOT and Patrol Employees Retirement System who are members of the Retirement System and are provided life insurance pursuant to Section 104.517.1 RSMo who have been split into the following classes: Class 1: Active Full-time, Permanent Part-time, disabled or seasonal employees of the

policyholder. Class 2: A former active Full-time, Permanent Part-time or seasonal employee of the

policyholder who retired on or after May1, 1982, but before May 1, 1984. Class 3: A former active Full-time, Permanent Part-time or seasonal employee of the

policyholder who retired on or after May1, 1984, but before September 1, 1988.

Class 4: A former active Full-time, Permanent Part-time or seasonal employee of the

policyholder who retired on or after September 1, 1988, but before May 1, 1996.

Class 5: A former active Full-time, Permanent Part-time or seasonal employee of the

policyholder who retired on or after May1, 1996, but before September 1, 1998.

Class 6*: A former active Full-time, Permanent Part-time or seasonal employee of the

policyholder who retired on or after September 1, 1998 and who was hired prior to July 1, 2000 who is eligible for and elects retiree coverage under the Retirement Closed Plan and who carried life insurance as an active employee.

Class 7*: A former active Full-time, Permanent Part-time or seasonal employee of the

policyholder who retired on or after July 1, 2000 and who is eligible for and elects retiree coverage under the Year 2000 Plan.

* Eligible Retirement Closed Plan employees may choose to retire with insurance

benefits as either a Class 6 or Class 7 retiree. Once the choice is made at retirement, the retiree will remain in the class chosen, he or she is not able to move between the two classes and he or she will only be covered as a retiree of one class. Under no circumstance will a Retirement Closed Plan retiree have benefits as both a Class 6 and Class 7 retiree.

ENROLLMENT PERIOD:

Not applicable for noncontributory insurance; 31 days from the first day of eligibility for contributory insurance. The first day of eligibility means the first day of the month following the employee’s first day of employment. For example, if the first day of employment is February 8th, the first day of eligibility is March 1st.

F. MHC-50393.24 Rev 3-2009 B

WAITING PERIOD: For Basic Life Insurance: None

For Optional Life Insurance: The period commencing with the employee’s date of employment and ending with the first day of the month next following with the employee’s date of employment. For Dependent Life Insurance: The period commencing with the employee’s date of employment and ending with the first day of the month next following with the employee’s date of employment.

MINIMUM HOURS PER WEEK REQUIRED:

The number of hours required for your job class.

CERTIFICATE EFFECTIVE DATE: The date that the certificate holder becomes insured under the group policy.

PLAN OF INSURANCE

EMPLOYEE BENEFIT SCHEDULE

EMPLOYEE TERM LIFE INSURANCE:

Basic Life Insurance

Eligible Class Amount of Basic Life Insurance Class 1:

Classes 2 – 7:

One* times annual benefit base rate of basic earnings, rounded to the next higher $1,000 if not already a multiple thereof, subject to a maximum of $250,000. * If a death occurs as a result of injury or disease occurring on or after the

effective date of insurance and arising out of and in the course of actual performance of duty as an employee, the Basic Amount of insurance will be an amount equal to three times the basic life insurance amount, subject to a maximum of $750,000.

None

Optional Life Insurance An amount elected by the employee from the following options: Eligible Class Amount of Optional Life Insurance Class 1:

Class 2:

Option 1: One, two, three, four, five or six times annual benefit base rate of basic earnings, multiplied and then rounded to the next higher $1,000 if not already a multiple thereof, subject to a minimum of $15,000 and a maximum of $800,000. Option 2: An amount elected by the employee, in an increment of $1,000, subject to a minimum of $15,000 and a maximum of the lesser of six times annual benefit base rate of basic earnings, multiplied and then rounded to the next higher $1,000 if not already a multiple thereof or $800,000. Employees can move in and out of Option 1 and Option 2. An employee who is moving from Option 1 to Option 2 will not be required to provide evidence of insurability as long as the flat dollar amount election under Option 2 is not more than the salary multiple election under Option 1. For an employee moving from Option 2 to Option 1 evidence of insurability is required for any salary multiple elected. An amount elected by the employee, in an increment of $500, subject to a maximum of $2,500.

F. MHC-50393.24 Rev 3-2009 C

Class 3: Class 4: Class 5: Class 6: Class 7:

An amount elected by the employee, in an increment of $500, subject to a maximum of $5,000. An amount elected by the employee, in an increment of $500, subject to a maximum of $10,000. An amount elected by the employee, in an increment of $500, subject to a maximum of $60,000. The amount of basic* and optional combined insurance in force as an active employee on the date immediately prior to the date of retirement, subject to a maximum of $60,000. The amount of optional insurance in force as an active employee the month immediately prior to the date of retirement. This optional insurance amount will remain in force for a retiree until age 62, at which time the insurance amount is subject to a maximum of $60,000.

* When a Class 1 employee retires as a Class 6 retiree, the basic life noncontributory coverage in force as an active Class 1 employee may be transferred to supplemental life insurance retiree coverage on a contributory basis.

GENERAL PROVISIONS FOR EMPLOYEE INSURANCE

CONTRIBUTORY/NONCONTRIBUTORY: Basic insurance is noncontributory insurance; supplemental insurance is

contributory insurance. GUARANTEED ISSUE AMOUNT: Guaranteed issue is the maximum amount of insurance an employee can receive

without evidence of insurability when first eligible under the plan provided enrollment is made within the enrollment period. The amounts are as follows:

For basic insurance: All basic insurance is guaranteed issue to the plan maximum of $250,000.

For optional insurance: For employees in an eligible class immediately prior to the

effective date of the group policy:

An amount equal to the amount of contributory insurance for which the employee was insured under the prior carrier’s group policy on the day immediately preceding the effective date of the group policy.

For employees who first become eligible after the effective date of the group policy: the lesser of six times the annual benefit base rate or $800,000

EVIDENCE OF INSURABILITY: Evidence of insurability is required as stated in the policy and for an amount of

insurance greater than the guaranteed issue amount.

EFFECTIVE DATE OF INCREASES AND DECREASES DUE TO CHANGE IN ELIGIBLE CLASS OR EARNINGS:

Increases due to a change in eligible class will become effective the date of the change in eligible class. Increases due to a change in earnings will become effective January 1st following the change in earnings. The change in coverage will be based on earnings as of July 31st of the previous year. Decreases due to a change in eligible class will become effective the date of the change in eligible class. Decreases due to a change in earnings will become effective the 1st of the month following the change in earnings. Evidence of insurability will not be required for an increase in insurance due solely to an increase in earnings. Employees in Class 1 who select Option 2 for coverage with the flat dollar amount will not receive a coverage increase due to an increase in earnings. All increases are subject to the actively at work requirement.

F. MHC-50393.24 Rev 3-2009 D

DEPENDENTS BENEFIT SCHEDULE

DEPENDENTS TERM LIFE INSURANCE:

Spouse Life Insurance

Eligible Class Amount of Spouse Life Insurance Class 1 and Class 6 and 7 employees retiring

with spouse coverage effective the month prior to retiring on or after May 1, 2006: Classes 2-5 and Class 6 and 7 employees who retired prior to May 1, 2006:

An amount elected by the employee, in an increment of $5,000, subject to a minimum of $15,000 and a maximum of the lesser of $100,000 or 100%* of the employee’s elected optional insurance amount. None

* Evidence of insurability is not required for an increase in the employee’s insurance due solely to an increase in earnings. However, the result of a salary increase for the employee does not automatically increase the spouse life insurance maximum of 100% of the employee’s elected optional insurance amount. An employee must initiate an election for an increase in the spouse coverage and evidence of insurability is required.

Child Life Insurance

Eligible Class Amount of Child Life Insurance Class 1:

Classes 2 – 7:

$15,000 An employee’s first eligible newborn child is automatically covered for $15,000 for 31 days from the child’s live birth. To continue coverage on the first child, the employee must elect child coverage within those 31 days; otherwise the coverage shall terminate at the end of the 31-day period. None

GENERAL PROVISIONS FOR DEPENDENTS INSURANCE

CONTRIBUTORY/NONCONTRIBUTORY: Dependents insurance is contributory insurance. GUARANTEED ISSUE AMOUNT: Guaranteed issue is the maximum amount of insurance an eligible dependent

can receive without evidence of insurability when first eligible under the plan provided enrollment is made within the enrollment period. The amounts are as follows:

For employees with eligible dependents immediately prior to the effective date

of the group policy, the guaranteed issue amount is equal to the amount of dependents insurance for which they were insured under the prior group policy.

For employees who first become eligible for dependents insurance after the

effective date of the group policy, the guaranteed issue amount is as follows: For spouse insurance: $15,000 For child insurance: $15,000

As an exception to child insurance, evidence of insurability is not required of a child when election is made at anytime throughout the plan year, including elections made outside initial eligibility, annual enrollment, or at a qualified status change as defined by the employer. However, if an election is made outside of initial eligibility, annual enrollment or at a qualified status change as defined by the employer, the death benefit paid within 31 days of said election will be limited to $3,000 if a death occurs within the first 31days of the election. The limited $3,000 benefit will automatically increase to the full child life benefit of $15,000, 31days after the effective date of the newly elected coverage.

F. MHC-50393.24 Rev 3-2009 E

EVIDENCE OF INSURABILITY: Evidence of insurability is required for a spouse as stated in the policy and for an amount of insurance greater than the guaranteed issue amount.

EFFECT OF EMPLOYEE’S RETIREMENT: All dependents insurance terminates upon the employee’s retirement except as

provided under the portability provision or as set forth for spouse coverage for a Class 6 or Class 7 retiree.

ADDITIONAL INFORMATION SUICIDE EXCLUSION FOR LIFE INSURANCE:

Applies only to employee optional life and spouse life insurance under this certificate.

SUPPLEMENT(S) TO THE CERTIFICATE Dependents Term Life Portability Accelerated Benefits


Definitions age

Attained age as of most recent birthday.

application

Your application for insurance under the group policy and, if required, your evidence of insurability application.

associated company

Any company which is a subsidiary or affiliate of the policyholder which is designated by the policyholder and agreed to by us to participate under the group policy.

certificate effective date

The date your coverage under this certificate becomes effective.

contributory insurance

Insurance for which you are required to make premium contributions.

earnings

Your annual benefit base rate of basic compensation not including commissions, overtime or premium pay, bonuses, or any other additional compensation. An employee’s annual benefit base rate of basic compensation is determined as of July 31st of the prior year or the employee’s date of hire, whichever is later.

employee

An individual who is employed by the policyholder or by an associated company. A sole proprietor will be considered the employee of the proprietorship. A partner in a partnership will be considered an employee so long as the partner’s principal work is the conduct of the partnership’s business. The term employee does not include temporary employees nor corporate directors who are not otherwise employees.

employer

The policyholder or any designated associated companies.

evidence of insurability

Evidence satisfactory to us of the good health of the prospective insured and any other underwriting information we require.

insured

A person who is eligible for and becomes insured according to the terms of this certificate.

non-work day

A day on which you are not regularly scheduled to work, including scheduled time off for vacations, personal holidays, weekends and holidays, and approved leaves of absence for non-medical reasons.

Non-work day does not include time off for medical leave of absence, temporary layoff, employer suspension of operations in total or in part, strike, and any time off due to sickness or injury including sick days, short-term disability, or long-term disability.

noncontributory insurance

Insurance for which you are not required to make premium contributions.

policyholder

The owner of the group policy as shown on the specifications page attached to this certificate.

specifications page

The outline which summarizes your coverage under the policyholder’s plan of insurance.

waiting period

The period, if any, of continuous employment with the employer required prior to becoming eligible for coverage under this certificate. The waiting period is shown on the specifications page attached to this certificate.

we, our, us

Minnesota Life Insurance Company.

you, your, certificate holder

The insured named on the specifications page attached to this certificate.

General Information What is your agreement with us?

You are insured under the group policy shown on the specifications page attached to this certificate. Your application as defined under this certificate is attached and is a part of this certificate. This certificate summarizes the principal provisions of the group policy that affect your life insurance coverage. The provisions summarized in this certificate are subject in every respect to the group policy.

Any statements made in your application as defined in this certificate will, in the absence of fraud, be considered representations and not warranties. Also, any statement made will not be used to void your insurance nor defend against a claim unless the statement is contained in the application attached to your certificate.


This certificate is issued in consideration of your application and the payment of the required premium.

Can this certificate be amended?

Yes. We retain the right to amend this certificate at any time without your consent. Any amendment will be without prejudice to any claim incurred for benefits prior to the date of the amendment.

Who is eligible for insurance?

You are eligible if you:

(1) are a member of the group and of an eligible class as defined in the group policy; and

(2) work for the employer for at least the number of hours per week shown as the minimum hours per week requirement on the specifications page attached to this certificate; and

(3) have satisfied the waiting period as shown on the specifications page attached to this certificate; and

(4) meet the actively at work requirement as shown in the section entitled “What is the actively at work requirement?”.

Are retired employees eligible for insurance?

If the policyholder’s plan of insurance, as reflected in the specifications page attached to this certificate, does not specifically provide insurance for retired employees, a retired employee shall not be eligible to become insured, nor have his or her insurance continued. If the policyholder’s plan of insurance specifically provides insurance for retired employees, the minimum hours per week and actively at work requirements will not apply to such persons.

What is the actively at work requirement?

To be eligible to become insured or to receive an increase in the amount of insurance, you must be actively at work fully performing your customary duties for your regularly scheduled number of hours at the employer’s normal place of business, or at other places the employer’s business requires you to travel.

If you are not actively at work on the date coverage would otherwise begin, or on the date an increase in your amount of insurance would otherwise be effective, you will not be eligible for the coverage or increase until you return to active work. However, if the absence is on a non-work day, coverage will not be delayed provided you were actively at work on the work day immediately preceding the non-work day.

Except as otherwise provided for in this certificate, you are eligible to continue to be insured only while you remain actively at work.

When will we require evidence of insurability?

Evidence of insurability will be required if:

(1) the specifications page attached to this certificate states that evidence of insurability is required; or

(2) the insurance is contributory and you do not enroll within the enrollment period shown on the specifications page attached to this certificate; or

(3) the insurance for which you previously enrolled did not go into effect or was terminated because you failed to make a required premium contribution; or

(4) during a previous period of eligibility, you failed to submit required evidence of insurability or that which was submitted was not satisfactory to us; or

(5) you are insured by an individual policy issued under the terms of the conversion right section.

When does insurance become effective?

Insurance becomes effective on the date that all of the following conditions have been met:

(1) you meet all eligibility requirements; and (2) if required, you apply for the insurance on forms

which are approved by us; and (3) we are satisfied with your evidence of insurability,

if we require evidence; and (4) we receive the required premium.

Can your coverage be continued during sickness, injury, leave of absence or temporary layoff?

Yes. The employer may continue your noncontributory insurance or allow you to continue your contributory insurance when you are absent from work due to sickness, injury, leave of absence, or temporary layoff.

Continuation of your insurance is subject to certain time limits and conditions as stated in the group policy. If you stop active work for any reason, you should discuss with the employer what arrangements may be made to continue your insurance.

Premiums When and how often are your premium contributions due?

Unless the policyholder and we have agreed to some other premium payment procedure, any premium contributions you are required to make for contributory insurance are to be paid by you to the policyholder on a monthly basis. We apply premiums consecutively to keep the insurance in force.

Can a premium be paid after the date it is due?

Yes. The group policy has a 31-day grace period. If a premium is not paid on or before the date it is due, that


premium may be paid during the 31-day period following the due date. The insurance under the group policy will remain in effect during the 31-day grace period. This grace period does not apply to the first premium payment.

How is the premium determined?

The premium will be the premium rate multiplied by the number of $1,000 units of insurance in force on the date premiums are due. The premium may also be computed by any other method on which the policyholder and we agree.

We may change the premium rate:

(1) on any premium due date following the expiration of any rate guarantee period, or following the date that the amount of insurance in force for any one coverage changes by more than 15% from that which was used to determine the current rates (active employee coverage and retiree coverage are considered separate coverages, as are basic life, optional life, spouse life and child life; or

(2) anytime, if the policy terms are amended or the total amount of insurance in force changes by 15% from the volume that was used to determine the current rates or more.

Death Benefit What is the amount of the death benefit?

The amount of the death benefit is the amount of insurance shown on the specifications page attached to this certificate.

Can you request a change in the amount of your contributory insurance?

Yes. If the policyholder’s plan of insurance, as reflected in the specifications page attached to the group policy, allows for a choice of amounts of insurance for your class, you can request an increase or a decrease in the amount of your contributory insurance within the limitations of the policyholder’s plan of insurance, including any limitations on when and how often such requests may be made.

If you request an increase in the amount of your contributory insurance, we will require evidence of insurability, unless otherwise noted on the specifications page.

When will changes in your coverage amount be effective?

Requested increases in the amount of your contributory insurance, if approved, are effective on the date we approve the increase. Requested decreases in the amount of your contributory insurance are effective on the first day of the month following receipt of your request for a decrease or if different, according to the administrative practices of the employer.

Requests for a change made during a special enrollment period offered by the employer will not become effective prior to the general effective date of elections made during that enrollment.

Increases and decreases in insurance amounts which result from a change in your eligible class or earnings will be effective as shown on the specifications page attached to this certificate.

All increases in the amount of insurance are subject to the actively at work requirement.

When will the death benefit be payable?

We will pay the death benefit upon receipt at our home office of written proof satisfactory to us that you died while insured under this certificate. All payments by us are payable from our home office.

The death benefit will be paid in a single sum or by any other method agreeable to us and the beneficiary. We will pay interest on the death benefit from the date of your death until the date of payment. Interest will be at an annual rate determined by us, but never less than 0.1% per year compounded annually, or the minimum required by state law, whichever is greater.

Payment of the death benefit will extinguish our liability under the certificate for which the death benefit has been paid.

To whom will we pay the death benefit?

We will pay the death benefit to the beneficiary or beneficiaries. A beneficiary is named by you to receive the death benefit to be paid at your death. You may name one or more beneficiaries. You cannot name the policyholder or an associated company of the policyholder as a beneficiary.

You may also choose to name a beneficiary that you cannot change without the beneficiary’s consent. This is called an irrevocable beneficiary.

If there is more than one beneficiary, each will receive an equal share, unless you have requested another method in writing. To receive the death benefit, a beneficiary must be living on the date of your death. In the event a beneficiary is not living on the date of your death, that beneficiary’s portion of the death benefit shall be equally distributed to the remaining surviving beneficiaries. In the event of the simultaneous deaths of you and a beneficiary, the death benefit will be paid as if you survived the beneficiary.

If there is no eligible beneficiary, or if you do not name one, we will pay the death benefit to:

(1) your lawful spouse, if living, otherwise; (2) your natural or legally adopted child (children) in

equal shares, if living, otherwise; (3) your parents in equal shares, if living, otherwise; (4) the personal representative of your estate.


Can you add or change beneficiaries?

Yes. You can add or change beneficiaries if all of the following are true:

(1) your coverage is in force; and (2) we have written consent of all irrevocable

beneficiaries; and (3) you have not assigned the ownership of your

insurance.

A request to add or change a beneficiary must be made in writing. All requests are subject to our approval. A change will take effect as of the date it is signed, but will not affect any payment we make or action we take before receiving your notice.

Termination When does your coverage terminate?

Your coverage ends on the earliest of the following:

(1) the date the group policy ends; or (2) the date you no longer meet the eligibility

requirements; or (3) the date the group policy is amended so you are

no longer eligible; or (4) 31 days (the grace period) after the due date of

any premium contribution which is not paid; or (5) the last day for which premium contributions have

been paid following your written request to cease participation under this certificate.

If your coverage under the group policy terminates due to non-payment of premiums, your coverage may be reinstated if all premiums due are paid and received by us within 31 days of the date of termination and during your lifetime.

Can your insurance be reinstated after termination?

Yes. When your coverage terminates because you are no longer eligible, and you become eligible again within thirty days after the date your coverage under this certificate terminated, your coverage may be reinstated.

Provided you are not then covered by an individual policy issued under the terms of the conversion right section, your coverage under the group policy shall be reinstated automatically, without evidence of insurability or satisfaction of any waiting period. Your amount of insurance will be that which applies to the classification to which you then belong, on the date you again become eligible. If the policyholder’s plan of insurance provides for contributory insurance under the group policy, your amount of contributory insurance will be limited to that for which you were insured immediately prior to the loss of coverage.

When your coverage terminates due to non-payment of premiums, your coverage under this certificate may be reinstated at any time within five years after date of default

in payment of premium provided you are not then covered by an individual policy issued under the terms of the conversion right section and upon presentation of evidence of insurability satisfactory to us and the payment of all premiums in arrears.

When does the group policy terminate?

The policyholder may terminate the group policy by giving us 31 days prior written notice. We reserve the right to terminate the group policy on the earliest of the following to occur:

(1) 31 days (the grace period) after the due date of any premiums which are not paid; or

(2) on any subsequent policy anniversary after the date the number of employees insured is less than any minimum established by us or as required by applicable state law; or

(3) 31 days after we provide the policyholder with notice of our intent to terminate the group policy.

Conversion Right What is the conversion right?

You may be able to convert this insurance to a new individual life insurance policy if all or part of your life insurance under the group policy terminates.

You may convert up to the full amount of terminated insurance if termination occurs because of termination of employment or because you move from one existing eligible class to another, or you are no longer in an eligible class.

Limited conversion is available if, after you have been insured for at least five years, insurance is terminated because:

(1) the group policy is terminated; or (2) the group policy is changed to reduce or terminate

your insurance.

In such case, you may convert up to the full amount of terminated insurance, but not more than the maximum. The maximum is the lesser of:

(a) $10,000; and (b) the amount of life insurance which terminated

minus any amount of group life insurance for which you become eligible under any group policy issued or reinstated by us or any other carrier within 31 days of the date your insurance terminated under the group policy.

Neither the conversion right nor the limited conversion right is available if your coverage under the group policy terminates due to failure to make, when due, required premium contributions.

Under both the conversion right and the limited conversion right, you may convert your insurance to any type of individual policy of life insurance then customarily issued


by us for purposes of conversion, except term insurance. The individual policy will not include any supplemental benefits, including, but not limited to, any disability benefits, accidental death and dismemberment benefits, or accelerated benefits.

How do you convert your insurance?

You convert your insurance by applying for an individual policy and paying the first premium within 31 days after your group insurance terminates. No evidence of insurability will be required.

How is the premium for the individual policy determined?

We base the premium for the individual policy on the plan of insurance, your age, and the class of risk to which you belong on the date of the conversion.

When is the individual policy effective?

The individual policy takes effect 31 days after the group insurance provided under the group policy terminates.

What happens if you die during the 31-day period allowed for conversion?

If you die during the 31-day period allowed for conversion, we will pay a death benefit regardless of whether or not an application for coverage under an individual policy has been submitted. The death benefit will be the amount of insurance you would have been eligible to convert under the terms of the conversion right section.

We will return any premium you paid for an individual policy to your beneficiary named under the group policy. In no event will we be liable under both the group policy and the individual policy.

Additional Information What if your age has been misstated?

If your age has been misstated, the death benefit payable will be that amount to which you are entitled based on your correct age. A premium adjustment will be made so that the actual premium required at your correct age is paid.

Is there a suicide exclusion?

The Additional Information section of the specifications page attached to this certificate indicates what insurance, if any, is subject to the suicide exclusion outlined below.

When applicable, this suicide exclusion limits our liability to an amount equal to the premiums paid if you, whether sane or insane, die by suicide within one year of the effective date of your insurance, or when applying for any subsequent increase in your amount of insurance.

If there has been an increase in your amount of insurance for which you were required to apply or for which we required evidence of insurability, and if you die by suicide

within one year of the effective date of the increase, our liability with respect to that increase will be limited to the premiums paid and attributable to such increase.

When does your insurance become incontestable?

Except for fraud or the non-payment of premiums, after your insurance has been in force during your lifetime for two years from the effective date of your coverage, we cannot contest your coverage. However, if there has been an increase in the amount of insurance for which you were required to apply or for which we required evidence of insurability, then, to the extent of the increase, any loss which occurs within two years of the effective date of the increase will be contestable.

Any statements you make in your application as defined under this certificate will, in the absence of fraud, be considered representations and not warranties. Also, any statement you make will not be used to void your insurance, nor defend against a claim, unless the statement is contained in the application attached to your certificate.

Can your insurance be assigned?

Yes. However, we will not be bound by an assignment of the certificate or of any interest in it unless it is made as a written instrument, and you file the original instrument or a certified copy with us at our home office, and we send you an acknowledged copy.

We are not responsible for the validity of any assignment. You are responsible for ensuring that the assignment is legal in your state and that it accomplishes your intended goals. If a claim is based on an assignment, we may require proof of interest of the claimant. A valid assignment will take precedence over any claim of a beneficiary.

Is the policyholder required to maintain records?

Yes. The policyholder is required to maintain adequate records of any information necessary for us to administer this certificate. We own the records relating to the insurance provided by this certificate, and can obtain them from the policyholder at any reasonable time.

If a clerical error is made in keeping records on the insurance under the group policy, it will not affect otherwise valid insurance. A clerical error does not continue insurance which is otherwise stopped. If an error causes a change in premium payment, we will make a fair adjustment.

Will the provisions of this certificate conform with state law?

Yes. If any provision in this certificate, or in the provisions of the group policy, is in conflict with the laws of the state governing the certificates or the group policy, the provision will be deemed to be amended to conform to such laws.

MHC-96-13187 Minnesota Life 1 EdF77746 9-2012

Dependents Term Life Insurance Certificate Supplement Minnesota Life Insurance Company - A Securian Company 400 Robert Street North • St. Paul, Minnesota 55101-2098 General Information This certificate supplement is issued in consideration of the required premium and is subject to every term, condition, exclusion, limitation, and provision of your certificate unless otherwise expressly provided for herein. Any Accidental Death and Dismemberment coverage provided by a certificate supplement to your certificate will not apply to dependents coverage provided by this certificate supplement.

What does this supplement provide?

This supplement provides insurance on the lives of your eligible dependents.

What members of your family are eligible for insurance under this supplement?

The following members of your family are eligible for insurance under this supplement:

(1) your lawful spouse who is not legally separated from you; and

(2) your unmarried children, stepchildren, legally adopted children and any other child related to you by blood or marriage who lives with you in a regular parent child relationship. Children are eligible from live birth (stillborn or unborn children are not eligible) to the attainment of age 26. Children age 26 or older are also eligible if they are physically or mentally incapable of self-support, were incapable of self-support prior to age 26 and are financially dependent on you for more than one-half of their support and maintenance.

If both parents of a child qualify as eligible employees under the group policy, the child shall be considered a dependent of both parents for purposes of this supplement. If any child qualifies as an eligible employee under the group policy, he or she is not eligible to be insured as a dependent child.

Any dependent child who, subsequent to the effective date of your child life insurance, meets the requirements of this provision will become insured on the date he or she so qualifies.

When will we require evidence of insurability?

Evidence of insurability will be required if:

(1) the specifications page attached to your certificate states that evidence of insurability is required; or

(2) the insurance is contributory and you do not enroll for coverage under this supplement within the enrollment period shown on the specifications page attached to your certificate; or

(3) dependents insurance for which you previously enrolled did not go into effect or was terminated because you failed to make a required premium contribution; or

(4) during a previous period of eligibility, you failed to submit evidence of insurability that was required for a dependent or that which was submitted was not satisfactory to us; or

(5) the dependent is insured by an individual policy issued under the terms of the conversion right of this supplement.

When does insurance on a dependent become effective?

Insurance on a dependent becomes effective on the date when all of the following conditions have been met:

(1) the dependent meets all eligibility requirements; and

(2) if required, you apply for dependents coverage on forms which are approved by us; and

(3) we are satisfied with the dependent’s evidence of insurability, if we require evidence; and

(4) we receive the required premium.

If a dependent is hospitalized or confined because of illness or disease on the date his or her insurance would otherwise become effective, his or her effective date shall be delayed until he or she is released from such hospitalization or confinement. This does not apply to a newborn child. However, in no event will insurance on a dependent be effective before your insurance is effective.

Death Benefit What is the amount of life insurance on each insured dependent?

The amount of life insurance on each insured dependent is shown on the specifications page attached to your certificate.

To whom will we pay the death benefit?

The death benefit payable under this supplement will be paid to you if living, otherwise to your estate.


Termination When does an insured dependent’s coverage under this supplement terminate?

An insured dependent’s coverage ends on the earliest of the following:

(1) the date the dependent no longer meets the eligibility requirements; or

(2) 31 days (the grace period) after the due date of any premium contribution which is not paid; or

(3) the last day for which premium contributions have been made following your written request that insurance on your eligible dependents be terminated; or

(4) the date you are no longer covered under the group policy.

You must notify us or your employer when a dependent is no longer eligible for coverage under this supplement so that premiums may be discontinued. All premiums paid for dependents who are no longer eligible for coverage under this supplement will be refunded without any payment of claim.

When does this supplement terminate?

This supplement will terminate on the earlier of:

(1) the date we receive a written request from the policyholder to cancel the Dependents Term Life Insurance Policy Rider; or

(2) the date the group policy is terminated.

Additional Information What is the conversion right under this supplement?

If an insured dependent’s coverage under this supplement terminates because he or she is no longer eligible, or because of your death, or because of termination or amendment of this supplement, the insurance may be converted to a policy of individual insurance with Minnesota Life.

Conversion may be requested by you, an insured dependent of legal capacity, or the insured dependent’s guardian, if applicable. All other conditions and provisions of the conversion right section of your certificate to which this supplement is attached will apply.

Secretary President

MHC-96-13215.24 Minnesota Life 1 EdF77748 9-2012

Term Life Insurance Portability Certificate Supplement Minnesota Life Insurance Company - A Securian Company 400 Robert Street North • St. Paul, Minnesota 55101-2098 General Information This certificate supplement is issued in consideration of the required premium and is subject to every term, condition, exclusion, limitation and provision of your certificate unless otherwise expressly provided for herein.


This supplement provides for continuation of your group life insurance if you no longer meet the eligibility requirements of your certificate, except as provided for herein.

To continue coverage under the provisions of this supplement, you must make a written request and make the first premium contribution within 31 days after insurance provided by the group policy would otherwise terminate. Evidence of insurability will not be required. Coverage provided by this supplement will then be deemed effective retroactive to the beginning of the 31-day period. This date is considered to be your portability date and you are then considered to have portability status.

Who is eligible to continue insurance under this supplement?

You are eligible to continue your group life insurance under the terms of this supplement if you, except as provided by this supplement, no longer meet the eligibility requirements of your certificate due to any of the following:

(1) you terminate employment, including retirement; or

(2) you are no longer in a class eligible for insurance or you are on a leave or layoff; or

(3) a class or group of employees insured under the policy is no longer considered eligible and there is no successor plan for that class or group. Successor plan means an insurance policy or policies provided by us or another insurer that replaces insurance provided under this policy.

You will not be eligible to request coverage under this supplement if you:

(1) have attained the age of 70; or (2) have converted your insurance to an individual life

policy under the terms of your certificate’s conversion right section; or

(3) were not actively at work due to sickness or injury on the date immediately preceding your portability date; or

(4) lose eligibility due to termination of the group policy.

What insurance can be continued under this supplement?

Both non-contributory and contributory insurance may be continued under this supplement. If you elect to continue your own coverage according to the provisions of this supplement, you may also elect to continue contributory insurance for any other individual insured under your certificate. You may also continue coverage under all supplements to your certificate which apply to non-contributory and contributory insurance and by which you were insured immediately preceding your portability date.

The amount of insurance continued under this supplement for any individual will be subject to any applicable state law or regulation relating to allowable amounts of insurance.

What is the minimum amount of insurance that can be continued under this supplement?

The minimum amount of insurance that can be continued on your life under this supplement is $10,000. This minimum does not apply to any other insureds covered under this supplement.

What is the maximum amount of insurance that can be continued under this supplement?

The maximum amount of insurance that can be continued under this supplement for an insured under age 65 is the amount of insurance that was in force on your portability date, but not more than $500,000 if you are an employee or $100,000 if you are a spouse. However, for an insured who is age 65 or older on his or her portability date, the amount will not be more than 65% of the amount in force on the insured’s portability date, to a maximum of $325,000 if you are an employee or $65,000 if you are a spouse.

Will the amount of insurance continued under this supplement change?

Yes. When an insured attains age 65, the amount of insurance on his or her life continued under this supplement will reduce to 65% of the amount of insurance in force on the day prior to attainment of age 65. Insurance terminates at age 70.

Can you request a change in your amount of insurance continued under this supplement?

Yes. You may elect to reduce the amount of insurance on your life. Your remaining amount of insurance must be at least $10,000.

MHC-96-13215.24 Minnesota Life 2 EdF77748 9-2012

The amount of insurance continued under this supplement will never increase.

How will premium contributions be paid?

Premium contributions will be paid directly to us on a monthly, quarterly, semi-annual, or annual basis and will be subject to an administrative charge per billing period. We may adjust the amount of the charge, but not more often than once per year.

Can the premium rate change?

Yes. The premium rate may increase on the portability date. The premium rate may also increase in the future but will not change more often than once per year.

Can insurance continued under this supplement be converted to a policy of individual insurance?

Yes. At any time after insurance has been continued under the provisions of this supplement, it may be converted to a policy of individual insurance with Minnesota Life. All other conditions and provisions of the conversion right section of your certificate to which this supplement is attached will apply.

What happens if you again become eligible under your certificate?

If you are continuing coverage under the terms of this supplement, and again meet the eligibility requirements of your certificate, not including the terms of this supplement, you shall no longer be considered to have portability status. Insurance may be continued only under the terms of your certificate, not including this supplement unless and until you no longer meet the eligibility requirements of your certificate and again return to portability status as provided for herein.

What happens to insurance provided under this supplement when the group policy terminates?

Anything in the group policy notwithstanding, termination of the group policy by the policyholder or us will not terminate life insurance then in force for any person under the terms of this supplement. The group policy will be

deemed to remain in force solely for the purpose of continuing such insurance, but without further obligation of the policyholder.

Any insurance continued under the terms of this supplement will remain in force until terminated by the provisions of the section entitled “When will insurance continued under this supplement terminate?”

No individual may elect coverage under this supplement on or after the date of termination of the group policy.

When will insurance continued under this supplement terminate?

Insurance being continued under this supplement will terminate on the earliest of the following:

(1) the insured’s 70th birthday; or (2) the date the insured again meet the eligibility

requirements of your certificate, not including the terms of this supplement; or

(3) in the case of a dependent child or a spouse who is insured by a supplement to your certificate, the date your coverage is no longer being continued under this supplement or the date the spouse or child ceased to be eligible as defined under the terms of your certificate; or

(4) 31 days after the due date of any premium contribution which is not made.

Secretary President


Accelerated Benefits Certificate Supplement Minnesota Life Insurance Company - A Securian Company 400 Robert Street North • St. Paul, Minnesota 55101-2098 Benefits received under this Accelerated Benefits Certificate Supplement may be taxable. You should seek assistance from a personal tax advisor prior to requesting an accelerated payment of death benefits.

General Information This certificate supplement is subject to every term, condition, exclusion, limitation, and provision of your certificate unless otherwise expressly provided for herein.


This supplement provides for the accelerated payment of either the full or a partial amount of an insured’s death benefit provided under your certificate. If an insured has a terminal condition as defined in this supplement, you may request an accelerated payment of the applicable death benefit.

Definitions accelerated benefit

The amount of the death benefit we will pay if the insured is eligible under this supplement.

death benefit

The amount of the insured’s life insurance as shown on the specifications page attached to your certificate.

immediate family

Your spouse, children, parents, grandparents, grandchildren, brothers and sisters, and their spouses.

insured

For purposes of this supplement, an insured employee, an insured spouse, or an insured dependent child.

physician

An individual who is licensed to practice medicine or treat illness in the state in which treatment is received. This does not include you or a member of your immediate family.

Terminal Condition What is a terminal condition?

A terminal condition is a condition caused by sickness or accident which directly results in a life expectancy of twelve months or less.

What evidence do we require of the insured’s terminal condition?

We must be given evidence that satisfies us that the insured’s life expectancy, because of sickness or accident, is twelve months or less. That evidence must include certification by a physician.

Do we have the right to obtain independent medical verification?

Yes. We retain the right to have the insured medically examined at our own expense to verify the insured’s medical condition. We may do this as often as reasonably required while accelerated benefits are being considered or paid.

Payment of Accelerated Benefit How do we calculate the accelerated benefit?

We will multiply the death benefit by the accelerated benefit factor to determine the accelerated benefit available.

How do we calculate the accelerated benefit factor?

The accelerated benefit factor will be stated as a percentage of the insured’s death benefit. When we calculate this factor, we will consider the insured’s age and gender.

We will also base our calculation on certain assumptions, which we may change from time to time, including but not limited to assumptions about:

(1) expected future premiums; and (2) the insured’s life expectancy.

What are the conditions for the payment of an accelerated benefit?

We will consider the payment of an accelerated benefit, subject to all of the following conditions:

(1) coverage must be in force and all premiums due must be fully paid; and

(2) application must be made in writing and in a form which is satisfactory to us. We will tell you what form is required; and

(3) you must be the sole owner of the certificate; and (4) the insured’s insurance must not have an

irrevocable beneficiary.


Who may request an accelerated payment of the death benefit?

You may request an accelerated payment of the insurance on your life or on the life of a spouse or dependent child insured under your certificate.

Is the request for an accelerated benefit voluntary?

Yes. An accelerated benefit will be made available on a voluntary basis only. An accelerated benefit under this supplement is not intended to cause an involuntary reduction of the death benefit ultimately payable to the named beneficiary. Therefore, payment of the death benefit cannot be accelerated under this supplement if the insured:

(1) is required by law to use this option to meet the claims of creditors, whether in bankruptcy or otherwise; or

(2) is required by a government agency to use this option in order to apply for, obtain, or keep a government benefit or entitlement.

Is there a minimum or maximum death benefit eligible for an accelerated benefit?

Yes. The minimum death benefit to be eligible for an accelerated benefit under this supplement is $10,000. The maximum death benefit to be eligible for an accelerated benefit is $1,000,000 (non-contributory and contributory insurance combined).

Do you have to take the entire accelerated benefit?

No. You may choose to receive a partial accelerated benefit. If you do so, the insured’s remaining coverage will stay in force.

If you elect to receive only a partial accelerated benefit amount available under this supplement, the insured’s remaining death benefit under the certificate must be at least $25,000.

You may reapply for the payment of the remaining amount of insurance at any time. However, we may ask for further satisfactory evidence that the insured meets all requirements for the accelerated benefit.

What is the effect on the insured’s coverage of the receipt of an accelerated benefit?

If you elect to accelerate the full amount of an insured’s death benefit, the insured’s coverage and all other benefits under the certificate and any certificate supplements for that insured will end. If such termination causes a certificate holder’s covered spouse or dependent

children to lose coverage, each of them will be allowed to convert any such insurance to a policy of individual life insurance according to the conversion right section of the certificate to which this supplement is attached.

If a partial accelerated benefit is chosen, coverage will remain in force and premiums will be reduced accordingly. The remaining amount of insurance under your certificate will be the full amount of insurance minus the amount of insurance that was accelerated.

How will we pay the accelerated benefit?

We will pay the accelerated benefit in one lump sum or in any other mutually agreeable manner.

To whom will we pay accelerated benefits?

All accelerated benefits will be paid to you unless you validly assign them otherwise. If you die before all payments have been made, we will pay the remainder to the beneficiary named under this certificate. Payment will be made in one lump sum which will be the present value of the payments that remain, using the interest rate we use to determine the payments.

Termination When does an insured’s coverage under this supplement terminate?

An insured’s coverage ends on the date the insured is no longer covered for life insurance under the group policy.

When does this supplement terminate?

This supplement will terminate on the earlier of:

(1) the date we receive a written request from the policyholder to cancel the Accelerated Benefits Policy Rider; or

(2) the date the group policy is terminated. Secretary President

Notice

Minnesota Life Insurance Company - A Securian Company

400 Robert Street North St. Paul, Minnesota 55105-2098A abcd

NOTICE CONCERNING COVERAGE

LIMITATIONS AND EXCLUSIONS UNDER THE MISSOURI LIFE AND

HEALTH INSURANCE GUARANTY ASSOCIATION ACT

Residents of this state who purchase life insurance, annuities or health insurance should know that the insurancecompanies licensed in this state to write these types of insurance are members of the Missouri Life and HealthInsurance Guaranty Association. The purpose of this Association is to assure that policyholders will be protected,within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If thisshould happen, the Guaranty Association will assess its other member insurance companies for the money to pay theclaims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extraprotection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted inthe box below, this protection is not a substitute for consumers' care in selecting companies that are well-managedand financially stable.

The Missouri Life and Health Insurance Guaranty Association may not provide coverage for this

policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and

require continued residency in Missouri. You should not rely on coverage by the Missouri Life and

Health Insurance Guaranty Association in selecting an insurance company or in selecting an

insurance policy.

Coverage is NOT provided for your policy or any portion of it that is not guaranteed by the insurer

or for which you have assumed the risk, such as a variable contract sold by prospectus.

Insurance companies or their agents are required by law to give or send you this notice. However,

insurance companies and their agents are prohibited by law from using the existence of the

Guaranty Association to induce you to purchase any kind of insurance policy.

YOU MAY CONTACT EITHER THE ASSOCIATION OR THE MISSOURI DEPARTMENT OF INSURANCE

AT THE FOLLOWING ADDRESSES SHOULD YOU HAVE ANY QUESTIONS REGARDING THIS

NOTICE.

The Missouri Life and Health Insurance Guaranty Association

994 Diamond Ridge, Suite 102Jefferson City, MO 65109

Missouri Department of Insurance

P. O. Box 690Jefferson City, MO 65102-0690

The state law that provides for this safety-net coverage is called the Missouri Life and Health Insurance GuarantyAssociation Act. On the back of this page is a brief summary of this law's coverages, exclusions and limits. Thissummary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations underthe act or the rights of obligations of the guaranty association.

(Please Turn to Back of Page)

FMHC-41633 Rev 2-2010

Generally, persons will be covered if they live in this state, and hold a life or health insurance contract or annuity, or acertificate under a group policy or contract. However, not all individuals with a right to recover under life or healthinsurance policies or annuities are protected by the Act. A person is not protected when --

1. The person is eligible for protection under the laws of another state.

2. The person purchased the insurance from a company that was not authorized to do business in thisstate.

3. The policy is issued by an organization which is not a member insurer of the association; or

4. The person does not live in this state, except under limited circumstances.

Additionally, the Association may not provide coverage for the entire amount a person expects to receive from thepolicy. The Association does not provide coverage for any portion of the policy where the person has assumed therisk, for any policy of reinsurance (unless an assumption certificate was issued), for interest rates that exceed aspecified average rate, for employers' plans that are self-funded, for parts of plans that provide dividends or credits inconnection with the administration of policy, or for unallocated annuity contracts (which are generally issued topension plan trustees).

The Act also limits the amount the Association is obligated to pay persons on various policies. The Association doesnot pay more than the amount of the contractual obligation of the insurance company. The Association does not haveto pay more than three hundred thousand dollars ($300,000) in death benefits for any one life regardless of thenumber of policies that insure that life. The Association does not have to pay amounts over one hundred thousanddollars ($100,000) in cash surrender or withdrawal benefits on one life regardless of the number of policies insuringthat individual. For health insurance benefits, the Association is not obligated to pay over one hundred thousanddollars ($100,000) including net cash surrender and withdrawal benefits. On an annuity contract, the Association isnot liable for over one hundred thousand dollars ($100,000) in present value. Finally, the Association is neverobligated to pay more than a total of three hundred thousand dollars ($300,000) for any one insured for anycombination of insurance benefits.

MISSOURI NOTICEabcd A AMinnesota Life Insurance Company 400 Robert Street North St. Paul, Minnesota 55101-2098

In the event you need to contact someone regarding this policy, you may contact the insurance company issuing thispolicy at the following address and telephone number.

Minnesota Life Insurance Company400 Robert Street NorthSt. Paul, MN 55101-2098

Telephone: (651) 665-3500

F. MHC-45280-G 10-1998

400 Robert Street North • St. Paul, Minnesota 55101-2098 GROUP TERM LIFE CERTIFICATE OF INSURANCE

employee group term life certificate of insurance · employee group term life certificate of...

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